Working at Intersection of Mental Health and Criminality

Benjamin Nordstrom, assistant professor of psychiatry at the Geisel School of Medicine and director of addiction services at Dartmouth-Hitchcock Medical Center, said the mental health system may be able to identify individuals in active treatment who present a violent threat, but “we are not so good at predicting violence in the community.”(Valley News - James M. Patterson) Purchase photo reprints »

Hanover — If Benjamin Nordstrom’s career path were represented as a Venn diagram, it would be made up of three circles: one for his study of the human body, when he was a student at Dartmouth Medical School; another for his study of the human mind, when he worked in New York psychiatric wards; and another for his background in criminology, for which he earned both a master’s and a doctoral degree from the University of Pennsylvania-Philadelphia.

It was this intersection of three interests that prompted the Valley News to contact Nordstrom in the wake of the mass killing of both children and adults in Newtown, Conn. What insight, if any, could the 37-year-old resident of Hanover provide on a subject that now consumes the American public?

An assistant professor of psychiatry at the Geisel School of Medicine and director of addiction services at Dartmouth-Hitchcock Medical Center, Nordstrom spoke with the Valley News about how mental health professionals and law enforcement can — and cannot — address this national issue. What follows is an edited version of that conversation.

Valley News: What are some of the major challenges in preventing mentally unstable people from committing acts of violence?

Benjamin Nordstrom: It’s a tough question to answer. But it’s important to point out at the outset that the vast majority of people who have mental illnesses are not violent. It’s actually a small number of diagnoses that lead to an increase of interpersonal violence.

One of the problems, I think, in why this keeps happening is that psychiatrists are not able to see into the future any better than anybody else. Studies that have been done show that psychiatrists can predict violence relatively well for people who are in-patients on a psychiatry ward. Psychiatrists can say with some certainty who is likely to become assualtive within the next 24 to 48 hours with that group of people. But historically we have been very poor at predicting who will become violent in the community.

The other part that’s probably worth mentioning is that there is not a huge amount of scholarly work done on mass murderers. But one of the papers that was done showed that, of this group that they had looked at, only 23 percent of them had been in contact with the mental health system prior to their act of violence. There’s a huge number of people who do this kind of thing who don’t have formal contact with mental health systems, so there wouldn’t be a way for the psychiatrists or psychologists to even opine on whether or not a person was dangerous.

VN: Do you see a role for community involvement in this issue?

BN: Potentially. One of the things that’s interesting is that about 75 percent of the people who go on to commit mass murders made some sort of comment, either a specific threat exactly about what they were going to do, or a specific enough threat about an actual act of violence. Usually they didn’t make it to a psychiatrist or a police officer, or somebody who would have the ability to intervene in some sort of formal way. But they said it to somebody. If people hear this kind of thing, it would be an act of social responsibility to find some way to get involved and to not try to just ignore it or round it down to idle chatter, but to really pursue it to make sure that the people who need to know this are in possession of the information.

VN: Who would those people be?

BN: It’s never wrong to tell the police when you hear something like that. Ultimately, they are the custodians of the public safety and they would be the ones who are in the best position to investigate it. If it happened in school, (people) could talk to the school counselor, talk to the school administration, reach out to that person’s family members. If that person does have a doctor or psychiatrist, (it’s OK) to call that doctor or psychologist and let them know that this was said. Confidentiality doesn’t mean you can’t say something to a person’s health care provider. That person might not be able to acknowledge that they’re treating the patient, or they might not be able to give any information back, but they can always listen. It won’t be ignored if a family member calls up and says, “I have some grave concerns and I understand you can’t say anything back to me, but let me tell you what I heard.”

To share that kind of information is a very important first step, because we know that, most of the time, these guys tipped their hand in some way.

VN: Are there specific behaviors that people can look for?

BN: It’s hard to get into the whole notion of profiling, but some of the things that have been learned about mass murderers is that the majority of them are often very, very interested in the military, they’re very interested in weapons, and that interest can clearly pre-date the time before they go on to commit one of these atrocities. They also tend to be socially isolated, which makes strengthening the community a tough issue. (But) if they’re doing (suspicious things) and they’re making threats, that’s the kind of situation where people should be talking. There should be a lot of activity to reach out to this person, to try to connect them with services or to really monitor them closely to make sure that something doesn’t spiral out of control.

A lot of these guys don’t have a mental illness in the way that most people think about mental illness. The majority of them are not psychotic. The majority of them actually have personality disorders, (which) is more of a persistent pattern of difficulty with relationships with other people, using less adaptive coping mechanisms for stress. To the average person interacting with somebody with a personality disorder, they would probably just find them very difficult people to associate with, but not necessarily suffering from a mental illness.

VN: Do you see a connection between violence in entertainment and violence in real life?

BN: I think that’s one of those things this is unknowable. When these events happen, they’re kind of like Rorschach tests. We all sort of see in them what we want to see. Some people look and see that this is all the result of having taken prayer out of school. Other people look at this and see that it’s all the result of people playing violent video games or watching violent movies. Other people look at it and think that it’s all referrable to people owning guns. Other people look at it and see it as a problem of not having access to mental health care in this country. There could be elements of truth to all of it. I don’t think it’s the sort of thing that can be boiled down to one factor because if we could, it would be a lot easier to stop. It’s sort of a perfect storm of a lot of things.

It’s worth pointing out, though, that this doesn’t just happen in America. This happens in other places as well. This isn’t something entirely unique to (the United States).

VN: What role do you see the media playing in these violent events?

BN: There certainly is a question about how much of this is a learned behavior in that people find something romantic about being an anti-hero and trying to achieve some level of infamy or notoriety by doing this and whether if in some way we’re playing into their hands by focusing on the murderers in cases like this. I wonder what would happen if the media never reported on the shooter’s identity, in the same way the media have decided not to report the names of victims of sexual assault.

VN: Can the mental health profession actually treat someone with a personality disorder that might lead to mass murder?

BN: There are very effective treatments for a number of personality disorders. The other part that frequently goes along with mass murderers is that there is a real or imagined loss that is about to happen. (They feel) there is going to be some catastrophic change in this person’s life, whether it’s the loss of a job, or some perceived insult. The dangerous thing about the kind of personality-disordered man who commits (mass murder) is that instead of internalizing the blame, this is a person who externalizes the blame. So he looks for reasons why other people are to blame for his problems.

The hope would be that, if this kind of person were in treatment, they could be helped to find other ways to cope with these perceived losses, a way of not externalizing the blame. That would be the hope from a mental health perspective.